| Certificate Number | 212 | | Date Issued |
| Child Given Name | Ellen May |
Keiger | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 May 1881 |
| Place of Birth |
| Father's Given Name | Hiram J. |
Keiger | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | | Father's Age |
| Mother's Given Name | Tobitha Ann | Lyons | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |